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Dear Colleague
Easter usually brings a
bewildering selection
of eggs. These colour-
ful eggs are Ukrainian,
and were featured on
www.bing.com last week.
In this issue we investigate the psychology of
choices, specifically frame selection.
We also look at ectopia lentis and we have a case
study on microbial keratitis in orthokeratology. On
the practice management front we give ways to
prevent fraud in the practice and illustrate the real
effects of inflation.
Happy reading
Nina Kriel
Ectopia Lentis
The dislocated lens was probably first described by
Berryat in 1749.1 A century later the term ectopia
lentis (EL) was introduced by Stellwag to describe
congenital dislocations but it was many years
before EL became recognised as an important
diagnostic clue to the possible presence of other
ocular or systemic disorders.
The most significant ocular manifestation of EL is a
reduction in VA. The severity of visual disturbance
varies with type and degree of dislocation and
the presence of associated ocular abnormalities.
Minimal subluxation of the lens may cause no
visual symptoms. However when the zonules are
disrupted, causing increased curvature of the lens,
the result may be lenticular myopia & astigma-
tism. Ectopia lentis continues to be a diagnostic
and therapeutic challenge for all eye care profes-
sionals. A thorough systemic and ocular evaluation
is necessary to establish the aetiology and to initi-
ate the appropriate therapeutic and prophylactic
measures. The aim of this article is to review the
approach to the patient with EL, the differential
diagnosis, the possible complications and overall
management.
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Events
Diagnostic Evaluation
The diagnosis of EL usually requires thorough evaluation with widely dilated pupils. Usually
the pupil is dilated with cyclopentolate 1% and phenylephrine 2.5% eye drops, unless
contraindicated. Patients should be specifically examined for irido- and phacodonesis,
and patients should be asked to look slightly inferiorly to identify lesser degrees of EL.
Phacodonesis is the quivering of the lens. (See video)
a. Family history: A complete detailed history from
the patients or the parents should be obtained prior
to ocular examination. Ask specifically about cardio-
vascular diseases and its complications, skeletal ab-
normalities and visual disturbance. A history of con-
sanguinity, early deaths in the family and mental re-
tardation are also important.
b. All patients with ectopia lentis should have a pae-
diatric or medical consultation to rule out systemic
diseases.
c. Establish VA early. A careful refraction is of para-
mount importance. Amblyopia is a common cause
for decreased vision in EL and if anisometropia is
present, it should be corrected optically.
d. Slit lamp examination: Detailed slit lamp examination
should include an evaluation of the iris, pupil, transillumina-
tion and iridodenesis, evaluation of the lens shape and po-
sition before and after dilation. Phacodenesis should be
evaluated by asking the patients to change gaze from
one objective of the slit lamp to another while the exam-
iner views the eye using the lowest magnification. EL varies
from mild displacement, evident only on maximal pupillary
dilation to significant subluxation, placing the equator of the lens in the pupillary axis.
e. Retinal examination is important in the evaluation of patients with EL. Peripheral retinal
signs include prominent white without pressure, lattice degeneration, and retinal holes.
f. Keratometric readings prior to retinoscopy may assist in determining the refraction of
these patients. Few studies have demonstrated the importance of keratometric values in
the diagnosis of Marfan Syndrome.
g. Patients with Marfan syndrome tend to have higher axial length than normal, so it is im-
portant to measure axial length in patients with EL.
Differential Diagnosis
Ectopia lentis has been described in which no other ocular and systemic abnormalities
have been detected, or it may also occur as common manifestation of systemic
disorders.
Genetic ectopia lentis without systemic manifestations:
Simple (familial) ectopia lentis: either as a congenital disorder or as spontaneous disorder
of late onset. Both are inherited in the majority of cases as autosomal dominant. Reces-
sive inheritance is rare and usually occurs in families with history of consanguinity.
Click here for phacodonesis video
It is usually manifested as bilateral symmetric, upward and temporal displacement of the
lens. Occasionally the degree of displacement varies considerably between the 2 eyes.
Spontaneous late onset subluxation of the lens occurs between 20-65 years. There is often
marked irregularity and degeneration of zonular fibers with subluxation of the lens inferi-
orly. Both types are associated with cataract and retinal detachment. Glaucoma is
more common in the late onset subluxation of the lens than in the congenital type.
Ectopia lentis et pupillae (ELeP) is a rare condition that usually exhibit autosomal recessive
inheritance pattern, although dominant pedigree has been described. Lenticular and
pupillary ectopia occur in opposite directions, resulting in an oval or slit shaped pupil,
poor pupillary dilation, axial myopia, glaucoma, megalocornea , and iris transillumination.
Ultrasound biomicroscopy studies indicate that the pathogenesis of this condition is
mechanical tethering of the pupil by membranous structure with coexisting zonular
disruption.
Systemic disorders commonly associated with ectopia lentis
1. Marfan syndrome: Marfan Syndrome (MFS) is autosomal dominant connective tissue
disorder associated with mutations in the Fibrillin-1 (FBN1) gene on chromosome 15q21.
FBN1 has been shown to be expressed in many organs, including the eyes, musculo-
skeletal, cardiovascular, and nervous system, as well as the lung and skin.
MFS affects both sexes and all ethnic groups with similar average severity. About one in
10,000 people are born with the disorder. Three out of every four people with MFS inherit
the disorder from a parent with the disease with spontaneous FBN1 mutations accounting
for the remaining 25-30% of cases. Diagnosis, therefore, continues to rely predominantly
on clinical examination and the observation of characteristic findings in multiple organ
systems. The latter have been summarized in the Ghent criteria which employs a set
of major and minor manifestations in numerous tissues requiring a family/genetic history
with a major criteria in one organ system and involvement of a third organ system. In pa-
tients with no family or genetic history, it requires major criteria in at least two different or-
gan systems and involvement of a third organ system. Associated skeletal abnormalities
include tall stature, arachnodactyly, chest wall deformities, and scoliosis. The typical car-
diac abnormalities are dilatation of the aortic root, mitral valve prolapsed, and aortic an-
eurysm formation. The only major criterion in the ocular system is EL, which is shown to be
a good predictor of disease in the evaluation of MFS. Other ocular findings in MFS are re-
corded, but appear to not be regularly evaluated -: iridodonesis - secondary to EL; flat-
tening of the cornea as measured by keratometry, megalocornea, axial myopia and
retinal detachment, and hypoplasia of the ciliary muscle found in association with iris
hypoplasia. Early development of nuclear cataract and open angle glaucoma are also
recorded as typical features of MFS. Lens subluxation in MFS could occur in any direction
but more commonly supratemporally. Zonular fibers in ectopia lentis are fewer in number,
thin, stretched and irregular in diameter.
2. Homocystinuria: Homocystinuria is a autosomal recessive disorder affecting
methionine metabolism. It is characterised by high serum levels of methionine and homo-
cystine. Affected individuals are normal at birth but they later develop seizures, osteopo-
rosis and mental retardation. They are also usually tall with light coloured hair.
Lens subluxation occurs in about 88% by the age of 15 years. They are usually subluxated
inferiorly and nasally.
3. Weill-Marchesani Syndrome: This is an autosomal recessive disorder in which af-
fected individuals are usually of short stature with brachycephaly and short fingers.
Microspherophakia has been reported with ectopia lentis in these patients.
4. Hyperlysinemia: This is an inborn error of metabolism of the amino acid lysine. Af-
fected individuals have mental retardation and muscular hypotony.
5. Sulfite oxidase deficiency: This is a very rare autosomal recessive disorder of sulfate
amino acid metabolism. In addition to ectopia lentis other manifestations include mental
retardation and seizures.
There are other ocular conditions associated rarely with ectopia lentis such as aniridia,
congenital glaucoma, and Rieger’s syndrome. However one of the common causes of
acquired subluxated lens is trauma.
Management of ectopia lentis
The primary aim for eyes affected by ectopia lentis is restoration of vision, avoidance and
treatment of amblyopia, and appropriate management of any complications such as
glaucoma. In many children, all that is necessary to correct acquired myopia/ astigma-
tism are optical measures alone. Spectacles can provide very satisfactory results espe-
cially where there is symmetrical refractive error. However in unilateral ectopia lentis,
the use of a CL may be necessary to avoid aniseikonia. If the crystalline lens is extensively
subluxated, correction of the refractive error of the aphakic zone of the pupil should be
tried. Coexistent pharmacological pupillary dilation can aid acceptance of this.
In severe cases of subluxated lenses, surgical intervention may be necessary through an
anterior segment approach or via pars plana vitrectomy with lensectomy.
In summary, ectopia lentis is an ocular disorder with diverse aetiologies. Each affected
individual should have a thorough family history that include whether cardiovascular,
skeletal or ocular abnormalities exist in other family members. Paediatric and medical
consultation is important to rule out any hereditary systemic disorders.
The prognosis for vision varies with type and degree of dislocation and the possible pres-
ence of ocular complications. Therefore emphasis needs to be directed toward early di-
agnosis and appropriate ocular rehabilitation.
Source
Eye on Ophthalmology: Ectopia Lentis
Altaie, R.
Reprinted with permission from
sNew Zealand Optics (June 2011)
Visit www.nzoptics.co.nz to subscribe
or to view archives.
Microbial Keratitis: A Case History
After parental discussion, a 14 year old male with
progressive -3.50DS OU myopia who had been
successfully wearing 2-weekly Acuvue Oasys
disposable soft contact lenses was fitted with
Menicon Z CRT™ overnight orthokeratology rigid
lenses. Although the ocular surface and tear film
appeared normal, there was a history of eczema
and seasonal atopy.
After 2 months of uneventful wear, the patient
started to experience a very sore RE over a week-
end, and was urgently referred from a local
[emergency section of the same medical centre]
on a Sunday afternoon.
Examination revealed a central erosion of the
right cornea with surrounding oedema. A small
hypopyon was present in the anterior chamber.
His vision was recorded as R CF@1m, L 6/24, both
eyes improving with pinhole to R 6/15, L 6/7.5.
A diagnosis of severe microbial keratitis over the
visual axis was made. The ulcerated area was
scraped and the patient commenced on Cefu-
roxime 5% every hour and fortified tobramycin
1.36% every hour, to be used alternately. He was
admitted to stay overnight in the hospital eye
department to ensure compliance, particularly
at night.
By the next day the patient reported that the eye
was feeling much better. His vision was recorded
as R 6/60 improving with pinhole to 6/30. The infil-
trate was found to have reduced and the epithe-
lium was now intact. Of note, the hypopyon that
was present at first examination was gone, with
only trace keratic precipitates present on the in-
ferior endothelium. The impression was therefore
that the lesion was healing rapidly and he was
allowed to go home. He was continued on tobra-
mycin 1.36% hourly and cefuroxamine 5% hourly,
used alternately, with instillation once overnight.
At the check the following day the stromal infiltra-
tive haze and associated oedema showed fur-
ther improvement so the medication was ad-
justed to hourly ciprofloxacin 0.3%.
Inflation
In 2002 Steers introduced the
King Steer Burger, the biggest on
the market at the time. It cost
R11.50 for the two 100g beef
pattie, two cheese slice, dill
pickle, onion, salad and
three sauce burger. Today, it
costs R39.90. The price has in-
creased 250% in 11 years, or a
compounded annual increase
of 13.3%.
The price of petrol in January
2002 was R3.61 in Gauteng. To-
day, a litre of 95 unleaded costs
R13.20 in Gauteng. This amounts
to an increase of 375% in 11
years. Stated differently, in 2002
you could buy a King Steer Bur-
ger and a litre of petrol in ex-
change for R15. Today, you
could only just get a litre of pet-
rol, and 7.5% of a King Steer Bur-
ger, maybe one bite.
In real terms, South Africans are
getting poorer as their salaries
cannot keep up with this kind of
price inflation. Now had we all
used gold as a medium of
exchange, the story would be
different. In exchange for an
ounce of gold you could get
290 King Steer Burgers in 2002.
Today, you can buy 330 King
Steer Burgers for the same
ounce. Likewise, you could buy
925 litres of petrol in 2002 for an
ounce of gold. Today, you can
buy 1100 litres.
How have your prices behaved
in the past decade?
Adapted from market strategist
and economist Chris Becker’s
article: www.moneyweb.co.za
Then the patient presented the following day saying that the right eye was feeling much
better, but now that the left eye was sore and red. Examination showed a central 6mm
diameter area of punctuate epithelial erosions. He was told to continue on the hourly
ciprofloxacin drops to the right eye and was given
Systane to be used qid to the left eye, with review.
At the next review, examination revealed a small cen-
tral scar with minimal haze in the right eye (see image),
whilst the left cornea was clear. He was commenced
on cyclosporine ointment to both eyelids BDS,
g Patanol OU BDS and the ciloxan was reduced to QID
to the right eye.
Optometry View: Grant Watters
Overnight orthokeratology (OK ) is starting to become more popular… especially with
increasing evidence that it may assist in myopia control in children and teenagers. It relies
on controlled compression of the central corneal epithelial cells by the fluid forces of the
tear film underneath a reverse geometry rigid contact lens. If the tear film is abnormal,
there is a chance that the lens could physically abrade the epithelial cells over the visual
axis. Although this patient allegedly had a normal tear break-up time, he had rosacea,
seasonal atopy, lid eczema and associated meibomian gland dysfunction.
The incidence of microbial keratitis with overnight OK has been hard to ascertain, but is
thought to be about 5 in 10,000 – similar to that of daily wear of soft contact lenses. There
have been reports of poor hygiene and contamination of lens cases and suction holders
contributing to problems in children in Hong Kong. There have also been concerns that
some fitters overseas have not provided adequate patient education and follow-up,
causing overnight OK to be outlawed in Singapore some years ago.
This teenager had a sore eye for several days before seeking help, but should have not
been wearing these lenses if his ocular surface was not in normal balance. It has been
well established that overnight wear of any contact lens carries higher risks of complica-
tions. It is also quite common for OK lenses to get protein deposits on their back surface,
which can affect lens comfort and performance and raise the risk of epithelial insult.
Fortunately aggressive treatment around the clock with fortified antibiotics ensured that
this patient did not suffer permanent visual loss. It is a traumatic experience for anyone
and not surprisingly, this patient has subsequently discontinued contact lens wear. He has
also had to continue lid treatment with cyclosporine ointment and ocular allergy man-
agement with Patanol. It can therefore be argued that this individual was not a suitable
candidate for OK and therefore rigorous screening guidelines must be identified and
adhered to. Hopefully other myopia control technologies such as multifocal soft lenses
and specially curved spectacle lenses will also gather momentum in the near future.
Ophthalmology View: Sacha Moore
This is a case of bacterial keratitis associated with orthoK lenses, with rapid response to
antibiotic treatment and residual scarring. Risk factors in this patient include teenage
age, eczema, atopy and overnight contact lens wear. Orthokeratology contact lenses
which are worn overnight and act by pressing against the cornea may have increased
risk of bacterial keratitis. Together, these risk factors made the likelihood of microbial
keratitis in this patient high. This reminds us of the importance of proper patient selection,
education and careful follow-up. Atopy in particular should be watched out for.
Cornea scrape followed by aggressive therapy as demonstrated in this case was appro-
priate. Knowledge of the corneal scrape result would have been helpful in determining
certainty of diagnosis, early treatment and future management. Non-bacterial infections
(acanthamoeba, herpes simplex virus or fungi) can sometimes appear to respond to anti-
biotics during the early phase of antibiotic treatment. The contact lens case should also
be sent for microbiological assessment if this was available. Confocal microscopy is a
further option for assessing for acanthamoeba infection…
Once sensitivities are known the treatment should be amended accordingly and tapered
in line with progressive resolution. Prolonged frequent use of antibiotics can be toxic to
epithelium and delay healing, especially if not preservative free. In the case of ciproflox-
acin drops this can result in crystalline deposits. In terms of trying to limit scarring there is
some debate as to whether topical steroids are useful. Steroids potentiate infection and
can mask the signs of inflammation allowing an infection to become rapidly worse. They
should only be used with extreme care by an experienced practitioner where there is a
high degree of certainty of the diagnosis. The patient was also known to have progres-
sive myopia with a history of atopy and eczema which may suggest keratoconus. This
should be assessed for in both eyes including corneal topography.
It would be helpful to know the dimensions of the ulcerated area and the area of
surrounding corneal infiltrate to allow quantification of resolution. The presence of
sloughy material or pus, subtarsal follicles or papillae and the degree of conjunctival
vascular engorgement or injection is also important to note. If the presenting ulcer is
less than 1mm diameter then corneal scraping is unlikely to yield results, may worsen the
epithelial defect or damage Bowman’s layer (causing scarring) or stroma, and could
seed infective organisms deeper into stroma. Alternatively it could be argued that epi-
thelial debridement can aid antibiotic penetration and remove infected tissue. Mono-
therapy with 24 hours of overnight hourly Ciprofloxacin drops tapering to four times a day
drops during waking hours for a further 3 days is appropriate for small ulcers. Where there
are concerns over compliance, admission is key. The patient should be advised to discon-
tinue contact lens wear until a few weeks after full resolution. The patient should then be
fully reassessed for CL fitting. They will need reinforcement of teaching on avoiding over
wear and how to correctly clean their lenses and store them. If the patient is unable to
do this, for whatever reason, they should be discouraged from further contact lens wear.
It would be important to question duration of contact lens wear as well as compliance
with the recommended cleaning regime. If the patient is deemed to have appropriately
used their contact lenses and complied with correct cleaning then details of lenses and
solutions used should be documented. This will be useful in future surveillance studies of
contact lens related problems.
Interestingly, topical cyclosporine was used in this case. This is indicated for mild, moder-
ate or severe dry eyes and to generally improve tear quality where this is thought neces-
sary, such as in atopic patients, as in this case. There are no reported adverse effects
other than irritation or inefficacy. The combination of Patanol and Cyclosporine would
benefit this atopic patient’s ocular surface, reduce likelihood of future similar problems
and carry less risk of complications than steroids in this setting of infectious keratitis.
Overall the patient was put on four different drops. The more drops the less likely the pa-
tient will comply with them correctly. Poor compliance is additionally problematic in
teenage patients as in this case. Reinforcement of advice, with written instructions or
printed information, and checking of what the patient is actually doing at each visit is
therefore required.
Source
Point of View: MK in OK— not OK!
Watters G, Moore S.
Reprinted with permission from New Zealand Optics (June 2011)
Visit www.nzoptics.co.nz to subscribe or to view archives.
The psychology of frame selection
Speed dating is a little like musical chairs. You
meet and chat with (i.e. ‘date’) someone for 5
minutes before a buzzer goes off and you move on
to the next person and do the same. At the end of
the evening where you may have met up to a dozen
people, you decide which of your speed dates you’d like to see
again. If both agree, then you set up a real date. Sander van der Lin-
den is a psychologist at the London School of Economics and Political
Science. His interest is behavioural change. He reports that he tried
speed dating a few years ago. The dating itself was an abysmal failure,
he says, but he has gathered some valuable information on how we make selections.
Let’s debunk some myths.
Spoilt for choice
Research shows that being confronted with a large number of choices can make it
harder to make a good decision. You may believe that having a large, varied selection
of frames is a good thing but research shows that speed daters found too much variety
(age, education, height, occupation) overwhelming. If there’s too much choice, daters
tend to make no choice at all! There may be plenty more fish in the sea, but we certainly
don’t want to bewilder our patients into not choosing a frame and going without correc-
tion, or being unhappy with their choice or going elsewhere to find a frame. In another
study it was shown that greater variety did not relate to a greater emotional satisfaction
than when there were fewer choices. It’s not about the confusingly large selection of fish
in the sea, then, but about finding the right one, in your small rock pool.
Like a kid in a candy store
Consumer behaviour has been extensively studied. Several experiments have shown
that we are more likely to make a choice (i.e. select something), and be happy with
our choice (whether it be jam or car tyres) when
the choice environment only offers a limited set
of options. We glibly use the expression ‘like a kid
in a candy store’ to describe the exciting initial
elation of overwhelming choice, but who really
makes successful choices when faced with a
whole candy store? I’d go for the pear flavoured
jelly beans every time. Such behaviour is exactly
what psychologists predict. Resorting to heuristics
is a coping mechanism. Van der Linden says that
heuristics are essentially ‘decision-making tools
that save effort by ignoring some information;
and thus, their essential function is to reduce
and simplify the processing of cues & information
from our environment. In other words, less is
more.’
Where there are a large number of speed dating
choices, participants tend to rely on heuristics,
and particularly on obvious/ easily accessible
information (height, age, physique) to make
decisions. Relating to frames, you may find that
a patient becomes flustered and quickly narrows
her search down to a familiar style, brand or col-
our. Where even those features of the frame are
to challenging, they resort to price shopping.
Everyone understands buying the cheapest.
It’s up to us to teach our patients the difference
between cheap and value-for-money. With a
lower number of speed dating options, partici-
pants used harder to observe attributes such as
occupation and education to guide decisions.
With a slightly smaller frame selection, and
armed with the correct information, we may be
able to get patients to look beyond the obvious
(price, colour) and get to fit, comfort, material
and shape.
Surely an informed and considered decision is
better than an intuitive choice? We tend to dis-
miss hasty decisions as irrational, but Gigerenzer
disagrees. Heuristics-based decision making isn’t
a cognitive shortcoming at all but rather the re-
sult of protective evolution. We have adapted to
make quick and accurate assessments in an un-
certain environment.
Small Business, Big Fall
Small businesses such may have
fewer employees and smaller
revenues, but we are even
more at risk for white collar
crime (e.g. fraud) than corpo-
rates. And with fewer reserves, it
could well be the end of the
road for an optometry practice.
Jenny Reid of iFacts suggests:
1. Hire trustworthy
personnel
Information about a potential
employee’s criminal record,
credit history, qualifications, ID
numbers and driver’s licenses
will reduce the risk of bringing
questionable individuals into
your practice.
2. Company policies &
procedures
You’re not too small to have
policies and procedures in
place for when an issue arises.
Clarity prevents you from react-
ing emotionally or inconsistently
when an issue arises, which is in
contravention of labour laws.
3. Set an example
Management needs to set
good ethical examples. Employ-
ees will respect and follow that
example. Practice what you
preach.
4. Training
Provide employees with rele-
vant training to expand their
knowledge and to grow. Em-
powerment and job satisfaction
reduce the temptation to risk
the job by committing a crime.
Research shows that we can make good
choices despite limited information. A group of
German students was asked to rank American
colleges, and did so more accurately than their
American counterparts. With more information,
we tend to overthink things and get it wrong.
Familiarity breeds contempt
According to the recognition heuristic, when
we are faced with 2 articles and recognise the
one, we infer that the recognised object has the
higher value. So familiarity does not always
breed contempt. Familiarity is reassuring and
suggests stability and certainty. Research shows
that we even pick shares on the stock market
that way!
Work your investment
Even if you have an on-site lab, your largest stock
investment is typically your frames. Make your in-
vestment work for you with these top tips for your
frame displays:
Group your frames according to price or
material or ladies/ gents/ unisex so that you
can easily limit a patient’s selection.
Save time by naming the group that you
have selected. ‘Here are the ladies plastic
frames which would be suitable for your
type of lens’ or ‘these children’s frames fall
within the budget that you have indicated.’
The limitation is for the patient, not for you to
stick to. Patients rely on us for guidance so
do try something a little different and gauge
the response. Ideally you want to get past
the point where they judge the superficial
attributes of the frame and start examining
things like comfort, quality and fit.
There’s little point in patients aimlessly wan-
dering around your dispensary trying on
frames. It’s a security risk and they’re likely to
choose inappropriate frames. Ask questions
to help them narrow down their choices.
Many patients choose their frames before
their examinations. If it’s a new patient, try
to gauge what they are likely to need
5. A little extra
Personnel are a company's
greatest asset. Invest in your
staff with incentives, wellness
assistance such as nutritional,
exercise, lifestyle and personal
financial advice. By instilling a
feeling of value you will create
an employee who is loyal,
honest and productive.
6. Prevention
Prevent crime by limiting the
opportunities, having good
systems in place and using
them. Do random spot checks.
Rotate staff and distribute
responsibilities.
For more information visit
www.ifacts.co.za.
Speak Up
84% of TopEnders aged 60 and
above will complain about bad
service when shopping (as op-
posed to keeping it to them-
selves). This is only the case for
57% of TopEnders aged 16 to 24.
(Source: RamsayMedia TopEnd
Survey 2011, Fact a Day 8
December 2012 on
www.eighty20.co.za)
by talking to them or checking their old glasses. Then set aside a few frames to
come back to after the examination. We do not emphasise the professional as-
pects of frame and lens selection enough.
I often end up going with the first frame we tried. We may look at a few others, but
then go back to the first. We have the knowledge and experience to know what
works so we are more likely to offer a suitable frame immediately, but we now un-
derstand that those first, intuitive choices are often the best.
Every practice needs a selection of conventional and predictable frames that will
satisfy and comfort the overwhelmed patient by introducing the familiar. It’s about
presenting the familiar with the less familiar, in a ratio that suggests that many of
your frames are suitable, but a unique choice is possible.
Select a few brands and keep enough of those brands to represent them. Beware
any company that insists on a specific or minimum stock-holding. Frames that
won’t sell (duplicates and inappropriate styles) are a waste of your money. A re-
sponsible supplier would want a mutually beneficial relationship. If they are overly
prescriptive, perhaps it’s not a match made in heaven. There are plenty of fish in
the sea.
A good selection is vital but your range can actually be too big. Not only do you
confuse, rather than impress your patients, but it plays havoc with your cash flow
and increases your holding costs.
Keep a selection of prices with enough high-end frames. Is a R750 frame expen-
sive? If it’s the most expensive frame in the practice, then yes, it’s expensive. You
need to stock R1500 frames to give context to your R750 frames. The patient must
feel that she has a choice. Remember, we’re talking speed dating, not an ar-
ranged marriage! High end frames are a greater investment but offer a better
return.
Depending on how you visually present your frames, your practice size and turn-
over, you should probably keep between 400 and 1200 frames with 15% or 1
month’s projected sales in surplus. A frame in your cupboard still has a holding cost
but without the current profit potential of a displayed frame.
Source
Speed dating and decision-
making: Why less is more
Van der Linden S
Scientific American
online (June 7, 2011)
Candy
chandelier
CPD instructions
Please e-mail your
answers to optometry
@synapse.org.za, in-
cluding your name and
HPCSA number.
Questions
1. Ectopia lentis may cause hyperopia, myo-
pia or astigmatism, depending on the de-
gree of dislocation and position of the lens.
2. The EL patient history should investigate
consanguinity, epilepsy and autoimmune
disease.
3. EL can only be seen on full dilation.
4. In congenital EL the lens is typically sub-
luxated asymmetrically, and drops down
and out.
5. Marfan syndrome patients usually have a
tall stature, arachnodactyly, chest wall de-
formities and scoliosis.
6. Rieger’s anomaly is one of the leading
causes of acquired EL.
7. Glaucoma is more common in patients with
EL.
8. Acanthamoeba and herpes simplex require
high doses of fortified antibiotics.
9. OrthoK is increasing in popularity due to its
potential to limit myopia progression.
10. Patients are most likely to make confident
frame choices when offered a very wide
and diverse range of frames.
Candy chandelier
This issue is taking on a bit of a
candy theme so I thought I’d
include this quirky chandelier
made of jelly bears.
To redecorate, simply eat the
installation and start again!
5000 Gummy Bear ’Candelier’
by Kevin Champeny
on www.demilked.com
CPD